Healthcare Provider Details

I. General information

NPI: 1306362165
Provider Name (Legal Business Name): STEPHENIE LOPEZ SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2017
Last Update Date: 08/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 E BELTLINE AVE SE
GRAND RAPIDS MI
49506-4300
US

IV. Provider business mailing address

96 MONROE CENTER ST NW STE 300
GRAND RAPIDS MI
49503-2947
US

V. Phone/Fax

Practice location:
  • Phone: 616-288-3732
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: